Is clinic’s $1,000 member fee innovative health care or an erosion of medicare?

During two-hour “bright futures” appointments, Dr. Karen Dockrill, a Toronto-area pediatrician, would produce an assortment of toys, sprawl out on the office floor and start playing with her young patients, trying to gauge their developmental progress. She also offered sessions with dieticians and breast-feeding consultants, round-the-clock telephone accessibility, a gymnasium and other services seldom associated with a Canadian physician’s office.

The impressive array of health care came at a cost, however, and the $1,000-plus “membership fees” she charged families may yet prove to be Dr. Dockrill’s downfall. She is getting set to fight rare charges by Ontario’s medical regulator that she essentially engaged in illegal private health care, putting on trial one of the most common challenges to the country’s publicly funded, universal health system. The doctor could face penalties ranging from a reprimand to suspension of her licence.

Dr. Dockrill said she knows of 106 primary-care physicians’ offices in Ontario that are running similar practices with mandatory “block fees” levied in exchange for enhanced service, while versions of the concept are running more or less openly in at least three other provinces.

Just this week, meanwhile, a report to the Canadian Medical Association recommended that user fees be considered to cope with the system’s increasing financial pressures, though the group’s leaders said they opposed the idea.

Dr. Dockrill is pondering a constitutional challenge of the rules that bar her from requiring patients to pay, saying she is proud of the service she offered at the fee-charging Mom and Baby Depot in Whitby, east of Toronto.

“I believe very much we need to do things in a different way,” she said. “This was to me a very good, innovative model designed for families … and I believe families have the right to this service. And as a physician, this is some of the best work I’ve ever done.”

To those who believe in a strong public health care system the creeping prevalence of such semi-private practices is nothing to celebrate. In fact, the College of Physicians and Surgeons of Ontario, the body that laid disciplinary charges against Dr. Dockrill, should be applauded for taking action where regulators have generally done little, said Dr. Danielle Martin, spokeswoman for Canadian Doctors for Medicare.

It’s one thing for a physician to offer additional or enhanced services for a voluntary fee, it is quite another to make the charge for such services mandatory, said

Dr. Martin.

“That’s a barrier to parents being able to get their children vaccinated, to parents being able to get their baby’s well-baby checks done,” she said. “It is highly important care that is paid for by our tax dollars. To require people to pay again for it is really inappropriate and unethical…. It is an insult to all of us who are paying taxes for equitable access to medically necessary health care.”

The idea has cropped up repeatedly in recent years; the most common form being perhaps so-called executive health-care centres. In most cases, the clinic charges medicare for services that are covered by public health insurance, and out-of-pocket fees for what some have dubbed “concierge” medicine — additional tests, preventive health counselling and longer doctor visits.

One of the most prominent is Copeman Healthcare Centre, which has branches in Vancouver and Calgary, offering paying clients an array of services from kinesiologists, psychologists and other health professionals and longer, “unhurried” appointments, as well as regular medical care.

It, too, has come under attack, with Ujjal Dosanjh, then the federal Liberal health critic, urging the Conservative government in January to investigate the Copeman clinic as a possible violation of medicare rules under the Canada Health Act.

While clinics such as Copeman that levy “block fees” argue they are charging for services that go above and beyond what medicare funds, critics maintain they essentially erect a financial obstacle to accessing physicians who also provide medicare-financed health care.

As a proponent of the quasi-private model, Dr. Dockrill hardly fits the profile of a radical, fringe practitioner. Before the latest controversy, the specialist had been head of neonatal care at Lakeridge hospital in neighbouring Oshawa. The idea for the Mom and Baby Depot was born out of an observation that parents with newborns often seemed confused about basic issues around their babies’ development, and that mothers’ own emotional issues frequently went unaddressed, she said.

Her business opened in 2006 after she surveyed local residents about the type of services they would like. The clinic ended up including access to staff nurses, dieticians, chiropractors and lactation consultants. There were also meeting rooms where professionals gave presentations, a community “kitchen” in which families could mingle, a gym, and the kind of quick access to a doctor that most Canadians would die for.

If a mother was having a particularly bad time — something called “Mommy crash” in the clinic — she could simply drop in for a visit. Dr. Dockrill was also on call at all hours. Then there were the two-hour visits that involved time with the physician and other professionals, nine of which could be booked in the infant’s first year. Medicare was billed $32 for those appointments, the standard fee.

Anne Kelly, a resident of Brooklyn, near Whitby, signed up when the first of two daughters was born three years ago, paying the monthly equivalent of a cable-TV bill, and said the services were a godsend, especially since both girls suffered from acid reflux. She said she often called the office during the day and got Dr. Dockrill on the phone. Calls at night were returned within minutes, said Ms. Kelly.

Some of those telephone conversations meant avoiding trips to the hospital emergency ward, she said.

“It was so worth it for us,” said Ms. Kelly. “There was a period where I probably called there every day for a couple of months … but no one ever made me feel like I was a bother. It was such a difficult time for us, I just can’t imagine how I would have gotten through it without the service.”

Dr. Dockrill said the mandatory fee was necessary to ensure she could keep those extra staff employed; since ending the service at the College’s behest, she has found many patients are unwilling to pay piecemeal for add-on care. And the response was enthusiastic, with 98% of the original 300 families deciding to stay with the Depot.

Dr. Dockrill was still handling specialist appointments referred to her by other doctors, and paid for by medicare. When one of those patients called and discovered that the broader service required her to pay a fee, she complained to the College, setting in motion the disciplinary process.

Dr. Dockrill agreed earlier this year to end the mandatory fees, but still faces charges over the membership charges.

“Physicians must not require that patients pay a block fee before accessing an insured service; physicians must not offer to treat patient preferentially because they pay a block fee,” said Kathryn Clarke, a spokeswoman for the regulator. “They must not terminate or refuse to take a new patient because they did not pay a block fee.”

The Ontario Medical Association, the chief representative for the province’s doctors, endorses those College rules, said a spokeswoman.

Dr. Dockrill said she has asked the regulator why other physicians with similar businesses have not also faced disciplinary action and said she was told those others had simply not been the subject of formal complaints. She said she is convinced she is being made an example for others.

“I’m assuming it’s a test case, but the process is underhanded.”

The pediatrician has had talks with the Canadian Constitutional Foundation, an Alberta-based group that champions legal challenges around generally conservative causes. The foundation would be interested in taking on the case, partly to assert the right of health professionals to run their practices as they see fit, said Karen Selick, the organization’s litigation director.

Even now, she noted, operations like the Mom and Baby Depot seem “rampant.”

Ms. Kelly said she was heart-broken when she heard that the disciplinary action had resulted in the service being ended.

“I almost cried,” said the mother. “I think it only improves on the health-care system we have now…. I feel sad that if I ever had a third, that wouldn’t be available to me.”

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